Visiting Veterinarian : On Martha's Vineyard, YouTube provides cherry eye surgery assist
Know what you get when you cross a beagle with a pug? A really cute puggle, like Elisha. He came to see me last month with a small red lump protruding from the corner of one eye. "He has had this before," his owner reported, "but, until this time, it has always gone away on its own."
I nodded absent-mindedly. After a long run of serious and complicated medical cases, it was a relief to see something simple. "Yup. It's 'cherry eye,'" I said.
Dogs and cats have a "third eyelid" in the inner corner of each eye that they can raise to cover and protect the eyeball. Also called the nictitating membrane or nictitans, it is normally barely visible, but a number of conditions will cause one or both to become elevated.
The most common situation is a lid raising in response to an eye injury. Elisha runs wildly through the woods and a branch pokes his eye. Elisha decides to play with the cat, and ends up with a scratched cornea. Occasionally a dog will injure both eyes, resulting in bilateral elevation of the nictating membranes. Like that Labrador I once saw who got way too chummy with an extremely pissed off skunk. (Can I say "pissed off" in the newspaper?) The curious retriever got blasted at close range with a direct hit to his eyes.
Now please remember, getting sprayed in the face by a skunk is rarely anything to worry about. Sure, it smells bad. Sure, dogs who get skunk juice in their mouths foam and drool like Ol' Yeller, but none of this requires medical intervention. I tend to get cranky when people call me on "emergency" in the middle of the night about their dog getting skunked.
Here's a tip. If you're looking for a recipe for skunk shampoo, contact Dr. Google, not Dr. Jasny. Let me sleep.
But I digress.
This particular dog was the rare skunk case that actually needed my expertise. Both nictitans were elevated to cover both eyes which had corneal ulcerations requiring topical medication, and follow-up monitoring. I have seen similar cases from chemical dips or strong shampoos splashed in dogs' eyes during bathing.
Not every elevated nictitans indicates a primary eye problem. Bilateral elevated third eyelids may occur when an animal is extremely sick or dehydrated. This is especially common in cats.
Then there's Horner's syndrome — a neurological disorder of the sympathetic nervous system, resulting in unilateral elevation of the nictitans, constricted pupil, and slight drooping of the regular lids on the affected side. It may be the result of trauma, infection, even cancer, but most cases are "idiopathic," i.e., without an identifiable cause. Idiopathic Horner's syndrome often resolves spontaneously and no treatment is indicated.
So which of these problems does our puggle, Elisha, have? None of the above. Although his nictitans is unusually prominent, it's not so much elevated as protruding with this round, red mass popping out from behind like a tiny piece of fruit.
What exactly is that little cherry? It's a gland that normally sits on the inside of the third lid, anchored in place by fibrous attachments. In certain dogs, weak attachments allow the gland to prolapse. Usually seen in pups under two years of age, cherry eye can occur in any dog. Certain breeds are predisposed, including cocker spaniels, bulldogs, beagles, bloodhounds, Lhasa apsos, Shih tzus, and other pug-faced dogs like, well, pugs.
Elisha, being half pug, half beagle, was obviously at risk. It's not uncommon for dogs to have intermittent episodes of the gland popping out, then back, but in most cases the gland eventually prolapses permanently, needing surgical repair. I sent Elisha home with ointment to apply and scheduled surgery the following week. "If it goes back to normal before then, call and cancel, " I said, "but don't hold your breath."
In the old days, cherry eye surgery was easy. Anesthetize dog. Cut off lump. Finito. Okay, sometimes you had to apply pressure to control bleeding, or use a hemostat, but that was it. Finito. The problem with that old school method was that this little gland has a purpose. It makes tears. Without the gland, a large percentage of post-surgical patients developed keratoconjunctivitis sicca, a.k.a. KCS or "dry eye." Lack of gland leads to lack of tears. Lack of tears leads to excessive dryness. Excessive dryness leads to irritation, excessive mucous production, and corneal damage with pigmentation and scarring that can result in blindness.
It soon became apparent to veterinarians that, although easy to do, cutting out the prolapsed gland was a bad idea. A variety of surgical techniques were developed to firmly replace the gland instead of removing it.
Not having done cherry eye surgery recently, I reviewed the literature and decided to use the "Morgan pocket technique," which I hadn't tried before. I kept reading the explanation of the procedure, but was having trouble visualizing it precisely. "Make two parallel incisions on the posterior aspect of the nictitans. Insert needle on the blah blah aspect of the blah blah..." and so on. Weren't there drawings or diagrams somewhere? I searched my data base, looked in books, combed through journals. Nothing.
Then I had an inspiration. YouTube. Entering "Morgan Pocket Technique," I got 40 results (although several turned out to be advertisements for pocket watches and other non sequiturs.) The best video demonstration was in Spanish with a rocking musical sound track. After watching it several times, I felt confident to proceed...and maybe go dancing.
Elisha's surgery went without a hitch and he looked great at his two-week recheck. Even with current techniques there is still a chance of both recurrence and subsequent dry eye after repair, but less so than previously. Sooner or later, many affected dogs will also prolapse the gland on the other side, but for Elisha, so far, so good. An easy diagnosis. A rocking Youtube tutorial. A successful outcome. A really cute puggle. A vet can't ask for more than that.